According to the American Heart Association (AHA), nearly 80 million adults have at least one type of cardiovascular disease (CVD), and it is the most deadly disease in the United States. Studies indicate that if CVD were completely eradicated, life expectancy could increase by nearly 7 years. In the July 27, 2010 issue of Circulation, the AHA released a scientific statement on individual-level interventions that are designed to promote physical activity and dietary lifestyle changes for cardiovascular risk factor reduction in adults. “Individual-level interventions that target dietary patterns, weight reduction, and new physical activity habits often result in impressive rates of initial behavior changes,” says Dariush Mozaffarian, MD, DrPH, who co-chaired the panel that developed the scientific statement. “Unfortunately, many of these behavioral changes are often not maintained for the long term.”
The purpose of the scientific statement is to provide evidence-based recommendations on individual-level strategies—for example, in the healthcare setting—for implementing physical activity and dietary interventions in all adults, regardless of racial or ethnic background and socioeconomic demographic. The most efficacious and effective strategies were summarized (Table), and guidelines were provided to translate these strategies into practice. The AHA committee reviewed 74 studies conducted among U.S. adults between 1997 and 2007. The studies measured the effects of behavioral change on blood pressure and cholesterol levels, physical activity and aerobic fitness, and diet. “There has been an explosion of data emerging on behavioral research and science over the past decade,” Dr. Mozaffarian notes, “and the time was right to systematically review the evidence base for behavioral strategies to improve physical activity and diet to reduce the burden of CVD.”
Cognitive Behavior Strategies Are Key
According to the AHA scientific statement, cognitive-behavioral strategies are an essential component of behavior change interventions. “These strategies focus on changing how individuals think about themselves, their behaviors, and surrounding circumstances,” explains Dr. Mozaffarian. “They also focus on how to modify patients’ lifestyle.” Data indicate that using at least two strategies—and preferably more—can yield substantially more favorable outcomes than using fewer cognitive behavioral strategies. The AHA scientific statement provides several Class I recommendations, which are supported with the strongest level of evidence, that Dr. Mozaffarian says should be recognized and utilized by clinicians. “For example,” he says, “setting targeted short-term goals at the outset is important to achieving desired behavior changes. Under most circumstances, setting such specific goals leads to greater behavior change when compared with too many goals or vague goals.” The use of goals is more successful when they’re specific in outcome, proximal in terms of attainment, and realistic in terms of the individual’s capability. Goals that focus on behavior rather than a physiological target are also preferable because patients can control their behaviors more directly.
After goals are set, consistent self-monitoring and extended follow-up and counseling with healthcare providers are recommended to help patients achieve lifestyle changes to reduce their CVD risk. Simple self-monitoring—such as recording diet or physical activity changes in a diary—is an established strategy to maximize lifestyle changes. Diet and exercise programs that incorporate scheduled follow-up sessions as a core component are also generally more effective. Healthcare provider or electronic feedback is also important as it helps patients learn new dietary or exercise behavioral skills by providing an external measuring stick against which to assess their progress. According to published data, motivational interviewing—a directive, individual-centered counseling style for eliciting behavioral changes—can also be beneficial when patients are ambivalent about behavior change.
Process & Delivery Strategies
Studies that assessed interventions such as providing educational materials, counseling sessions, and follow-up monitoring have been variable with regard to findings, but most report positive results. “Media messages, printed materials, and other non-individualized educational strategies may be useful to encourage physical activity and dietary changes,” says Dr. Mozafarrian, “but these materials may not encourage patients to maintain these behavioral changes over a lifetime. Other approaches can also benefit patients, such as group-based, individual-based, computer/technology-based, and multi-component interventions. However, clinicians need to determine which of these additional interventions make the most sense for each individual patient.”
Healthcare System Changes Needed
The AHA scientific statement notes that current healthcare policies should be modified to encourage use of behavioral interventions for physical activity and diet changes. Dr. Mozaffarian says “the evidence-base for behavior change strategies is now clear, so the remaining challenge is the translation of this knowledge into action. To help with this translation, it’s important to 1) disseminate this information, 2) educate clinicians through training, 3) facilitate processes for physicians with tools, 4) change reimbursement plans, and 5) develop quality guidelines and metrics to incorporate diet and exercise behavior changes.”
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